Form Approved
OMB Number 0935-0118
Expiration Date 01/31/2013

MEDICAL PROVIDER COMPONENT

FOR REFERENCE YEAR 2010

CONTACT GUIDE FOR HOSPITALS

VERSION 1.0

MEDICAL PROVIDER COMPONENT
FOR REFERENCE YEAR 2010

CONTACT GUIDE FOR HOSPITALS

SECTION MR_A:  CALL PROVIDER

MR_A1. [N/A]  (READ IF NOT OBVIOUS: (Hello) Have I reached (PROVIDER)?)

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR),
  -OR- SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.

• IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER.

• IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE PROVIDER. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE PROVIDER.

• IF NO BETTER NUMBER IS AVAILABLE, SELECT "NO" BELOW.

YES ............... = 1 (GO TO MR_ A2 PRELOGIC)
NO ................ = 2 (GO TO EXIT SCREEN)

MR_A2.[N/A]  I have [an] authorization form[s] for the release of medical records and would like to speak to the person who can help me with that process.

• IF THE PERSON YOU NEED TO TALK TO IS UNAVAILABLE ATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

• IF RECORDS ARE KEPT BY A MEDICAL RECORDS SERVICE, ASK TO SPEAK WITH THE PERSON IN THE OFFICE WHO DEALS WITH THE MEDICAL RECORDS SERVICE.

  
  

CONTINUE = 1 (GO TO MR_B1)
NO MEDICAL RECORDS DEPARTMENT; NOT CLEAR WHO TO SPEAK TO = 2 (GO TO EXIT SCREEN)

SECTION MR_B:  IDENTIFY DC POC

MR_B1 [MR INTRODUCTION FOR RESPONDENT]

(READ IF NECESSARY: (Hello,) my name is (YOUR NAME). I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of medical records and would like to speak to the person that can help me with that process.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON,
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

  PERSON IS ON THE PHONE ......................... = 1 (GO TO MR_B2)
  PERSON IS NOT AVAILABLE/CALL BACK ............ = 2 (GO TO APPOINTMENT SCREEN)

MR_B2. [S1]  I'd like to verify that this is a hospital, hospital outpatient department, hospital satellite clinic, surgi-center, or a skilled nursing facility?

YES ......................................... 1 (GO TO MR_B4)
NO ............................................ 2 (GO TO MR_B3a)

MR_B3a. [S2]  How would you describe this facility? Is this:

A doctor's office;
A publicly-funded clinic;
An urgent care center;
A home care provider;
A long term care facility such as a nursing home;
Or Something else? (SPECIFY:___________)

IF YES TO ANY ABOVE, TERMINATE CALL & CODE APPROPRIATELY

(READ IF NECESSARY: A hospital outpatient department, hosppital satellite clinic, surgi-center, or skilled nursing facility?)

IF RESPONDENT REPORTS HOSPITAL OUTPATIENT DEPARTMENT, HOSPITAL SATELITE CLINIC, SURGI-CENTER, OR SKILLED NURSING FACILITY, GO BACK TO ITEM MR_B2 - ELIGIBILITY - VERIFY HOSPITAL AND CODE ACCORDINGLY.

[GO TO MR_B3b UNLESS RESPONDENT REPORTS FACILITY IS HOSPITAL. IF RESPONDENT REPORTS FACILITY IS HOSPITAL, RETURN TO B2 AND CHOOSE 1.]

MR_B3b.  I'm sorry. The information I was hoping to collect today is specific to hospital outpatient departments, hospital satellite clinics, surgi-centers, or skilled nursing facilities. Because this facility is not one of these, one of my colleagues will be calling back to collect the necessary information.

CLICK NEXT TO GO TO THE EXIT SCREEN. ONCE YOU EXIT, CODE THE CASE AS "PROVIDER INELIGIBLE"

[GO TO EXIT SCREEN]

MR_B4 [MR INTRODUCTION FOR RESPONDENT]

At this time, [NUMBER FROM PATIENT LIST] patient(s) identified (FACILITY) as a source of health care during 2010. (The/Each) patient signed an authorization form allowing us to contact you for information about the care they received from (FACILITY) in 2010. Much of the information we need is within the medical records. Are the medical records maintained in your office, or is a medical records service used?

• IF ASKED, CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.

• IF THE PERSON ON THE PHONE IS NOT SURE, ASK TO SPEAK WITH/BE TRANSFERRED TO SOMEONE WHO WOULD KNOW ABOUT THE MEDICAL RECORDS FORM 2009 AND RESTART THIS SECTION,
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

OFFICE MAINTAINS THE INFORMATION = 1 (GO TO MR_B4b)
OFFICE USES A MEDICAL RECORDS SERVICE = 2 (GO TO MR_B4_1)

MR_B4_1.  Are you the person who deals with the medical records service?

YES.........................= 1 (Go to MR_C2)
NO...........................= 2 (Go to MR_B4a)

MR_B4a.  I'll need to collect the name and telephone number for the person in your office who deals with the medical records service.

[GO TO CONTACT BLOCK]

MR_B4b.  [MR1]   I would like to fax the authorization form(s) to you, along with additional information explaining the study. I need to be sure I have the correct information for the packet. Should I direct it to you?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE WILL:

  1. PROVIDE THE DATA,
  2. JUST NEEDS A COURTESY PACKET, OR,
  3. HAS TO GIVE PERMISSION.

• IF ASKED, CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.

• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.

  • IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION.
  • IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION.

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

  YES ........ = 1
  NO ......... = 2

  [GO TO CONTACT BLOCK].

  
  

MR_B5.  Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs to receive the forms) to approve the release of data?

YES....................... = 1 (GO TO CONTACT BLOCK)
NO......................... = 2 (GO TO EXIT SCREEN)

• IF PERSON ON PHONE SAYS YES, YOU WILL BE TAKEN TO THE CONTACT BLOCK. ADD THE PERSON WHO NEEDS THE PERMISSION/COURTESY PACKET TO THE CONTACT BLOCK, THEN GO TO SECTION MR_F: DC: EXPLAIN NEXT STEPS.

• IF PERSON ON PHONE SAYS NO, YOU WILL BE TAKEN TO THE EXIT SCREEN. BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION MR_C:  identify mr service

MR_C1.  (READ IF NECESSARY: (Hello,) my name is (YOUR NAME).)

I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of medical records and would like to speak to the person that can help me get in touch with the medical records service that maintains your records.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON, -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH   ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

  PERSON IS ON THE PHONE.........................= 1 (GO TO MR_C2)
  PERSON IS NOT AVAILABLE/CALL BACK........................= 2 (GO TO APPOINTMENT SCREEN)

MR_C2.  (READ IF NECESSARY: At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2010. [The/Each] patient signed an authorization form allowing us to contact you for information about the care they received from [PROVIDER] in 2010.)

We should be able to get all of the information we need from the medical records service. We can also fax you a copy of the authorization form[s] for your files.

I need to be sure I have the correct information for the packet. Should I direct it to you?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE:

1. DEALS WITH THE EXTERNAL RECORDS SERVICE,
2. JUST NEEDS A COURTESY PACKET, OR
3. HAS TO GIVE PERMISSION.
   
   
• IF ASKED CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.
  
  
• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL
  
  
• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK:
  
  
• IF PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION.
• IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION.
• IF ADDING A COURTESY PERMISSION PACKET RECIPIENT, ADD/EDIT BOTH POCS IN THE CONTACT BLOCK.
  
  
• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S)]: In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

YES.........................= 1
NO...........................= 2

[GO TO CONTACT BLOCK]

MR_C3.  Can you please provide the name of the medical records service, the name of a contact person, their telephone number and title?

YES.........................= 1 (GO TO CONTACT BLOCK)
NO...........................= 2 (GO TO EXIT SCREEN)

• IF PERSON ON THE PHONE SAYS YES, ADD THE NEW PERSON TO THE CONTACT BLOCK, then exit and call the medical records service.

• IF PERSON ON PHONE SAYS NO, ask to speak with someone who can provide this information AND RESTART THIS SECTION.  if no one can, exit and BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION MR_D:  CALL MR SERVICE

MR_D1.  (READ IF NOT OBVIOUS: (Hello) Have I reached [MEDICAL RECORDS SERVICE]?)

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR),
  -OR- SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.

• IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER.

• IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE MEDICAL RECORDS SERVICE. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE MEDICAL RECORDS SERVICE.

• IF NO BETTER NUMBER IS AVAILABLE, SELECT "NO" BELOW.

YES.........................= 1 (GO TO MR_D2)
NO..........................= 2 (GO TO EXIT SCREEN)

MR_D2. (Hello) We were referred to you by [PROVIDER] about [NUMBER FROM PATIENT LIST] of their patients who received medical service in 2010. I have [an] authorization form[s] for the release of medical records and would like to speak to the person that can help me with that process.

IF THE PERSON YOU NEED TO TALK TO IS UNAVAILABLE ATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

CONTINUE = 1 (GO TO MR_E1).
SERVICE DOES NOT MAINTAIN 2010 RECORDS FOR PROVIDER =2 (GO TO EXIT SCREEN).
NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER  = 3 (GO TO EXIT SCREEN).

SECTION MR_E:  MR SERVICE:  IDENTIFY POC

MR_E1.  (READ IF NECESSARY: (Hello,) my name is (YOUR NAME).)

I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.

POC:

(READ IF NECESSARY: I have [an] authorization form[s] for the release of medical records and would like to speak to the person that can help me with that process.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON AND RESTART THIS SECTION, -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.
  

  PERSON IS ON THE PHONE.........................= 1 (GO TO MR_E2)
  PERSON IS NOT AVAILABLE/CALL BACK..........................= 2 (GO TO APPOINTMENT SCREEN)

MR_E2. We were referred to you by [PROVIDER] for information about one or more of (his/her/their) patients. At this time, [NUMBER FROM PATIENT LIST] patient[s] signed an authorization form allowing us to contact you for information about the care they received from [PROVIDER] in 2010.

I would like to fax the authorization form[s] to you, along with additional information explaining the study.
I need to be sure I have the correct information for the packet. Should I direct it to you?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE WILL:
  
  1. PROVIDE THE DATA,
  2. JUST NEEDS A COURTESY PACKET, OR
  3. HAS TO GIVE PERMISSION.
  
  

• IF ASKED CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.

• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.

  • IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION,
  • IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION.

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

YES.........................= 1
NO..........................= 2

[GO TO CONTACT BLOCK]

MR_E3.  Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs to receive the forms) to approve the release of data?

YES.........................= 1 (GO TO CONTACT BLOCK)
NO...........................= 2 (GO TO EXIT SCREEN)

• IF PERSON ON PHONE SAYS YES, YOU WILL BE TAKEN TO THE CONTACT BLOCK. ADD THE PERSON WHO NEEDS THE PERMISSION/COURTESY PACKET TO THE CONTACT BLOCK, THEN GO TO SECTION MR_F: DC: EXPLAIN NEXT STEPS.

• IF PERSON ON PHONE SAYS NO, BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION MR_F:  DC:  EXPLAIN NEXT STEPS

MR_F1. [MR4]  Once you have received the authorization form(s) (and permission to release data to us has been given to you,) if # of patients is < or =25, show "we will call back to collect the data over the phone", if # of patients is >25, show "you can send us the medical records by either fax or mail, or we will call back to collect the data over the phone."]. For each date of service in 2010, we are requesting information about diagnoses and services, and the names of the physicians who treated each patient in 2010.

(In order for permission to be granted, we will send the authorization forms as a part of a study packet.)

IF THE PERSON ON THE PHONE EXPRESSES A CONCERN ABOUT PROVIDING DATA OVER THE PHONE,
SAY "You can also send us the billing records by either fax or mail."

PROVIDER WILL RESPOND:

BY PHONE....................................................................... 1 (GO TO MR_F2)
BY FAX............................................................................ 2 (GO TO MR_F3)
BY MAIL........................................................................... 3 (GO TO MR_F3)

MR_F2.  Within the next 24 hours we will [fax/mail] you the authorization form[s] and include an instruction sheet. If you have any questions about the information we will need, please call our toll-free number on the instruction sheet. We will allow time for you to receive and review the authorization form[s], and then we will call you back to verify that you have received the form[s]. When we call back, we'll also work with you to set up a good time to collect the data over the phone (once you've received permission to release the data).

We may call again if other patients identify this facility as a source of medical services.

[GO TO MR_F4]

MR_F3.  Within the next 24 hours we will [fax/mail] you the authorization form[s] and include an instruction sheet. If you have any questions about what to send us, please call our toll-free number on the instruction sheet. We will call you back to verify that you have received the form[s]. We hope you can send the records to our office within two weeks.

We may call again if other patients identify this facility as a source of medical services.

[GO TO MR_F4]

MR_F4. [MR6]  We are also interested in the charges and the summary of payments for each date of service in 2010. Can you provide this information?

YES ...................... 1 (GO TO CONTACT BLOCK)
NO.2 ..... (GO TO MR_F4a)

MR_F4a. [MR7] Can you please provide the name and number for whom we should contact to obtain this information?

YES............................1 (GO TO CONTACT BLOCK)
NO..............................2 (GO TO MR_F5)

MR_F5. [MR8]  Lastly, we are interested in collecting the names and locating information for the providers who treated each patient while they received services in this facility during 2010. Can you provide this information as well?

YES................................. 1 (GO TO CONTACT BLOCK)
NO ................................. 2 (GO TO MR_F5a)

IF YES YOU WILL BE TAKEN TO THE CONTACT BLOCK AND EDIT THE CURRENT POC. THEN EXIT THE CONTACT GUIDE VIA THE EXIT SCREEN.

MR_F5a. [MR9] Can you please provide the name and number for whom we should contact to obtain this information?

YES............................1 (GO TO CONTACT BLOCK)
NO..............................2 (GO TO EXIT SCREEN)

IF YES YOU WILL BE TAKEN TO THE CONTACT BLOCK AND EDIT THE CURRENT POC. THEN EXIT THE CONTACT GUIDE VIA THE EXIT SCREEN.

SECTION MR_G:  VERIFY RECEIPT OF AFS

MR_G_Intro.  May I please speak to [POC NAME]?

PERSON IS ON THE PHONE.........................= 1 (GO TO MR_G1)
PERSON IS NOT AVAILABLE..........................= 2 (GO TO APPOINTMENT SCREEN)

MR_G1.  (Hello, my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.

(We've confirmed that the authorization form[s] we sent in order to receive permission for the release of information [have/has] been received.)

Did you receive the authorization form[s] we [faxed/mailed] to you?

YES, RECEIVED ALL = 1 (IF MR_F1 = 1 GO TO MR_G2. IF MR_F1 = 2 OR 3 GO TO MR_G4)
YES, BUT PROBLEM REPORTED/NEEDS A RE-SEND  = 2 (GO TO MR_G5)
NO = 3 (GO TO MR_G5)

MR_G2.  If it is convenient for you, we can just go ahead and complete the data forms together over the phone right now.
I'd be happy to hold on while you get the information you need from your records.

WILL COMPLETE BY PHONE NOW  = 1 (GO TO EXIT SCREEN)

WILL COMPLETE BY PHONE IN THE FUTURE =  2 (GO TO MR_G3)

IF THE POC WANTS TO COMPLETE BY PHONE NOW, YOU WILL EXIT THE CONTACT GUIDE AND RETURN TO CMS. CODE THE CASE AS "AUTHORIZATION FORMS RECEIVED - READY FOR PHONE DATA COLLECTION". THEN, PROCEED TO THE PATIENT LISTING SCREEN TO BEGIN EVENT FORM DATA COLLECTION.

MR_G3. [MR5]  I understand. What would be the best day and time to call you back to complete the data forms?

• PROBE FOR THE BEST DATE AND TIME.
  
• IF THE POC IS HESITANT TO PROVIDE AN EXACT TIME OR DATE:
  -ASK WHICH DAY OF THE WEEK IS BEST
  -ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING GUIDELINES FOR SCHEDULING:
  • EARLY MORNING = 9AM
  • LATE MORNING = 11AM
  • EARLY AFTERNOON = 2PM
  • LATE AFTERNOON = 4PM

  DAY:

  DATE:

  TIME: (HRS/MINS)

  TIME ZONE:

  [GO TO EXIT SCREEN]

MR_G4.  Our records indicate that you will [fax/mail] the records to us.  We hope you can do so within two weeks.

YOUR NEXT STEP WILL BE TO EXIT THE CONTACT GUIDE AND CODE THE CASE AS "AFs RECEIVED. WAITING FOR RECORDS TO BE SENT."

[GO TO EXIT SCREEN]

MR_G5.  I'm sorry.  Let me re-send the authorization form[s] to you.

I need to be sure I have the correct information for the packet.  Should I direct it to you?

YES = 1
NO = 2

• IF ASKED CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING NFORMATION

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first.  Once you have received the form[s], then we can arrange for the collection of the data.

• CLICK NEXT TO PROCEED TO THE CONTACT BLOCK AND ENTER OR EDIT CONTACT INFORMATION FOR THE POC WHO SHOULD RECEIVE THE PACKET, THEN EXIT THE CONTACT GUIDE AND CODE THE CASE IN CMS.

[GO TO CONTACT BLOCK]

SECTION MR_H:  BAD MR SERVICE INFO

MR_H1.  ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE

This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services.
For quality assurance and training purposes, this call may be monitored.

We previously spoke about the MEPS study. Thank you for providing the contact information for [MEDICAL RECORDS SERVICE NAME]. Unfortunately we were unable to locate [MEDICAL RECORDS SERVICE NAME] with the contact information you provided. Could you please verify the contact information we currently have for [MEDICAL RECORDS SERVICE NAME]?

MEDICAL RECORDS SERVICE CONTACT INFO IS CORRECT =1 (GO TO MR_H2)

MEDICAL RECORDS SERVICE CONTACT INFO IS NOT CORRECT =2 (GO TO CONTACT BLOCK)

MR_H2. That is currently the information we have on file. Do you know of any other way we can get in touch with [MEDICAL RECORDS SERVICE NAME]?

YES = 1 (GO TO CONTACT BLOCK)
NO = 2 (GO TO EXIT SCREEN)

IF PERSON ON THE PHONE SAYS NO, BE SURE TO CODE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION MR_I:  ANY OTHER MR SERVICE?

MR_I1. ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE

This is (YOUR NAME)calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored.

We previously spoke about the MEPS study. Thank you for providing the contact information for [MEDICAL RECORDS SERVICE NAME]. We were able to locate [MEDICAL RECORDS SERVICE NAME] with the information you provided. However, they reported that they did not maintain the medical records for [PROVIDER(S)] in 2010. Could you please check to see if another medical records service maintained medical records for [PROVIDER(S)] in 2010?

OTHER MEDICAL RECORDS SERVICE MAINTAINED RECORDS =1 (GO TO CONTACT BLOCK)
NO OTHER MEDICAL RECORDS SERVICE MAINTAINED RECORDS =2 (GO TO EXIT SCREEN)

IF PERSON ON THE PHONE SAYS NO, BE SURE TO CODE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

RECONCILIATION SCREEN (After MR sections have been completed, the system will check whether there are multiple providers in the contact group. If there are multiple providers, the following question will be seen.)

CONTROL SYSTEM WILL FLAG IF PROVIDER IS PART OF CONTACT GROUP:

IF CONTACT GROUP................................................................ 1 (ASK FOLLOWING QUESTION)
IF NOT A CONTACT GROUP..................................................... 2 (EXIT)

Before we send you the authorization form(s), I'll need to determine that all of the providers I have listed were in fact associated with this practice during 2010. I'm going to read you a list of providers, and for each one, please tell me if each one was associated with this practice in 2010.

IF A PROVIDER IS NOT ASSOCIATED WITH THIS PRACTICE IN 2010, CHECK THE BOX NEXT TO THEIR NAME.  IF NO PROVIDERS ARE REMOVED FROM THE LIST, YOU MUST STILL CLICK SAVE BELOW.

SECTION PA_A:  CALL PROVIDER

PA_A1.  (READ IF NOT OBVIOUS: (Hello) Have I reached [PROVIDER]?)

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR),
  -OR- SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.

• IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER.

• IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE PROVIDER. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE PROVIDER.

• IF NO BETTER NUMBER IS AVAILABLE, SELECT "NO" BELOW.

YES........................= 1 (GO TO PA_A2)
NO..........................= 2 (GO TO EXIT)

PA_A2.  I have [an] authorization form[s] for the release of billing records and would like to speak to the person that can help me with that process.

• IF THE PERSON YOU NEED TO TALK TO IS UNAVAILABLE, ATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

• IF RECORDS ARE KEPT BY AN EXTERNAL BILLING SERVICE, ASK TO SPEAK WITH THE PERSON IN THE OFFICE WHO DEALS WITH THE EXTERNAL BILLING SERVICE.

CONTINUE = 1 (GO TO PA_B1)
NO BILLING DEPARTMENT; NOT CLEAR WHO TO SPEAK TO  = 2 (GO TO EXIT SCREEN)

SECTION PA_B:  IDENTIFY DC POC

PA_B1. [INTRODUCTION FOR RESPONDENT]

(READ IF NECESSARY: (Hello,) my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of billing records and would like to speak to the person that can help me with that process.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON, -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

PERSON IS ON THE PHONE.........................= 1 (GO TO PA_B2)
PERSON IS NOT AVAILABLE/CALL BACK..........................= 2 (GO TO APPOINTMENT SCREEN)

PA_B2.  [INTRODUCTION FOR RESPONDENT]

At this time, [NUMBER FROM PATIENT LIST] patient(s) identified (FACILITY) as a source of health care during 2010.  (The/Each) patient signed an authorization form allowing us to contact you for information about the cost of the care they received from (FACILITY) in 2010 Much of the information we need is within the billing records. Are the billing records maintained in your office, or is an external billing service used?

• IF ASKED CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION

• IF THE PERSON ON THE PHONE IS NOT SURE, ASK TO SPEAK WITH/BE TRANSFERRED TO SOMEONE WHO WOULD KNOW ABOUT THE BILLING RECORDS FROM 2010 AND RESTART THIS SECTION,
  -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH -
  ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

OFFICE MAINTAINS THE NFORMATION ... 1 (GO TO PA_B2b)
OFFICE USES AN EXTERNAL BILLING SERVICE ... 2 (GO TO PA_B2_1)

PA_B2_1.  Are you the person who deals with the external billing service?

YES = 1 (go to PA_C2)
NO = 2 (go to PA_b2a)

PA_B2a.  I'll need to collect the name and telephone number for the person in your office who deals with the external billing service.

PRESS "NEXT" TO GO TO THE CONTACT BLOCK. ADD THE NEW POC TO THE CONTACT BLOCK AND CALL THEM USING SECTION PA_C: IDENTIFY BILLING SERVICE.

[GO TO CONTACT_BLOCK]

PA_B2b.  DID THE PERSON ON THE PHONE MENTION THAT THEY DID NOT NEED TO RECEIVE AUTHORIZATION FORMS BECAUSE THEY HAVE ALREADY BEEN SENT TO MR?

NO, SEND AUTHORIZATION FORMS TO PA ... 1 (GO TO PA_B2c)
YES, NO NEED TO SEND AUTHORIZATION FORM(S) TO PA POC ... 2 (GO TO PA_B2c)

PA_B2c. [PA1]  [IF PA_B2b=1 FILL "I would like to fax the authorization form(s) to you, along with additional information explaining the study. I need to be sure I have the correct information for the packet. Should I direct it to you?"
[IF PA_B2b=2 FILL "I'll need to fax you some basic information about the study. Should I address the fax to you?"]

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE WILL:
  

  1. PROVIDE THE DATA,
  2. JUST NEEDS A COURTESY PACKET, OR
  3. HAS TO GIVE PERMISSION,

• IF ASKED CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.

• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.

  • IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION
  • IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S):  In order to remain HIPAA compliant, I need to send you the authorization form[s] first.  Once you have received the form[s], then we can arrange for the collection of the data.

YES ................... = 1
NO .................... = 2

[GO TO CONTACT BLOCK]

PA_B3.  Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs to receive the forms) to approve the release of data?

YES .............. = 1 (GO TO CONTACT BLOCK,)
NO .............. = 2 (GO TO EXIT SCREEN.)

• IF PERSON ON THE PHONE SAYS YES, YOU WILL BE TAKEN TO THE CONTACT BLOCK. ADD THE PERSON WHO NEEDS THE PERMISSION/COURTESY PACKET TO THE CONTACT BLOCK,
  THEN GO TO SECTION PA_F: DC: EXPLAIN NEXT STEPS.

• IF PERSON ON PHONE SAYS NO, YOU WILL BE TAKEN TO THE EXIT SCREEN. BE SURE TO CODE THE CASE AS "CASE REQURIES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION PA_C:  IDENTIFY BILLING SERVICE

PA_C1.  (READ IF NECESSARY: (Hello,) my name is (YOUR NAME).)

I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

(READ F NECESSARY: I have [an] authorization form[s] for the release of billing records and would like to speak to the person that can help me get in touch with the external billing service that maintains your records.)

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON, AND RESTART THIS SECTION
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH -
  ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

PERSON IS ON THE PHONE.........................= 1 (GO TO PA_C2)
PERSON IS NOT AVAILABLE/CALL BACK........................= 2 (GO TO APPOINTMENT SCREEN)

PA_C2.  (READ IF NECESSARY: At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2010. [The/Each] patient signed an authorization form allowing us to contact you for information about the cost of the care they received from [PROVIDER] in 2010.)

We should be able to get all of the information we need from the billing service.
We can also fax you a copy of the authorization form[s] for your files.

I need to be sure I have the correct information for the packet. Should I direct it to you?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE
  

  1. DEALS WITH THE EXTERNAL BILLING SERVICE,
  2. JUST NEEDS A COURTESY PACKET, OR
  3. HAS TO GIVE PERMISSION,

• IF ASKED CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.

• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.

  • IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION.
  • IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION.
  • IF ADDING A COURTESY PERMISSION PACKET RECIPIENT, ADD/EDIT BOTH POCS TO THE CONTACT BLOCK.

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S):  In order to remain HIPAA compliant, I need to send you the authorization form[s] first.  Once you have received the form[s], then we can arrange for the collection of the data.

YES .................. = 1
NO .................... = 2

[GO TO CONTACT BLOCK]

PA_C3.  Can you please provide the name of the billing service, the name of a contact person, their telephone number and title?

YES ....................... = 1 (GO TO CONTACT BLOCK)
NO ........................ = 2 (GO TO EXIT SCREEN)

• IF PERSON ON THE PHONE SAYS YES, ADD THE NEW PERSON TO THE CONTACT BLOCK, then exit and call the billing service.

• IF PERSON ON PHONE SAYS NO, ask to speak with someone who can provide this information AND RESTART THIS SECTION. if no one can, exit and BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION PA_D:  CALL BILLING SERVICE

PA_D1.  (READ IF NOT OBVIOUS:  (Hello) Have I reached [BILLING SERVICE]?)

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR),
  -OR- SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.

• IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER.

• IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE BILLING SERVICE. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE BILLING SERVICE.

• IF NO BETTER NUMBER IS AVAILABLE, SELECT  NO  BELOW.

YES ............... = 1 (GO TO PA_D2)
NO..........................= 2 (GO TO EXIT SCREEN)

PA_D2. (Hello) We were referred to you by [PROVIDER] about [NUMBER FROM PATIENT LIST] of their patients who received medical service in 2010. I have [an] authorization form[s] for the release of billing records and would like to speak to the person that can help me with that process.

IF THE PERSON YOU NEED TO TALK TO IS UNAVAILABLE ATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

CONTINUE = 1 (GO TO PA_E1)
SERVICE DOES NOT MAINTAIN 2010 RECORDS FOR PROVIDER =2 (GO TO EXIT SCREEN)
NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER = 3 (GO TO EXIT SCREEN)

SECTION PA_E:  BILLING SVC: IDENTIFY POC

PA_E1.  (READ IF NECESSARY: (Hello,) my name is (YOUR NAME).)

I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of billing records and would like to speak to the person that can help me with that process.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON AND RESTART THIS SECTION,
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH -
  ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

  PERSON IS ON THE PHONE ...................... = 1 (GO TO PA_E2)
  PERSON IS NOT AVAILABLE/CALL BACK ........................ = 2 (GO TO APPOINTMENT SCREEN)

PA_E2. We were referred to you by [PROVIDER] for information about one or more of (his/her/their) patients.  At this time, [NUMBER FROM PATIENT LIST] patient[s] signed an authorization form allowing us to contact you for information about the cost of the care they received from [PROVIDER] in 2010. For each date of service in 2010 we are asking for the charges and the summary of payments.

I would like to fax the authorization form[s] to you, along with additional information explaining the study.
I need to be sure I have the correct information for the packet.  Should I direct it to you?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE WILL:
  

  1. PROVIDE THE DATA,
  2. JUST NEEDS A COURTESY PACKET, OR
  3. HAS TO GIVE PERMISSION,

• IF ASKED CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.

• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.

  • IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION
  • IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC'S CONTACT INFORMATION

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S):  In order to remain HIPAA compliant, I need to send you the authorization form[s] first.  Once you have received the form[s], then we can arrange for the collection of the data.

YES ................... = 1
NO .................... = 2

[GO TO CONTACT BLOCK]

PA_E3.  Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs to receive the forms) to approve the release of data?

YES ...................... = 1 (GO TO CONTACT BLOCK)
NO ....................... = 2 (GO TO EXIT SCREEN)

• IF PERSON ON THE PHONE SAYS YES, YOU WILL BE TAKEN TO THE CONTACT BLOCK. ADD THE PERSON WHO NEEDS THE PERMISSION/COURTESY PACKET TO THE CONTACT BLOCK, THEN GO TO SECTION PA_F: DC: EXPLAIN NEXT STEPS.

• IF PERSON ON PHONE SAYS NO, BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION PA_F:  DC:  EXPLAIN NEXT STEPS

PA_F1. [PA4]  Once you have received the authorization form(s)/information explaining the study] (and permission to release data to us has been given to you,) [if # of patients is < or =25, show "we will call back to collect the data over the phone", if # of patients is >25, show "you can send us the billing records by either fax or mail, or we can call back to collect the data over the phone."]  For each date of service in 2010, we are collecting the amounts charged for services before any adjustments or discounts, and the sources and amounts of payment.

(In order for permission to be granted, we will send the authorization forms as a part of a study packet.) 

IF THE PERSON ON THE PHONE EXPRESSES A CONCERN ABOUT PROVIDING DATA OVER THE PHONE, SAY "You can also send us the billing records by either fax or mail." 

PROVIDER WILL RESPOND:

BY PHONE ............................................ 1 (GO TO PA_F2)
BY FAX .............................................. 2 (GO TO PA_F3)
BY MAIL ............................................. 3 (GO TO PA_F3)

PA_F2.  Within the next 24 hours we will [fax/mail] you the [authorization form[s]/information explaining the study] and include an instruction sheet. If you have any questions about the information we will need, please call our toll-free number on the instruction sheet. We will allow time for you to receive and review the [authorization form[s]/information explaining the study], and then we will call you back to verify that you have received the [form[s]/information]. When we call back, we'll also work with you to set up a good time to collect the data over the phone (once you've received permission to release the data).

We may call again if other patients identify this facility as a source of medical services.

[IF MR_F5=2 AND MR_F5a=2, GO TO PA_F4, ELSE GO TO EXIT SCREEN.]

PA_F3.  Within the next 24 hours we will [fax/mail] you the [authorization form[s]/information explaining the study]  and include an instruction sheet. If you have any questions about what to send us, please call our toll-free number on the instruction sheet.  We will call you back to verify that you have received the [form[s]/information]. We hope you can send the records to our office within two weeks.

We may call again if other patients identify this facility as a source of medical services. 

[IF MR_F5=2 AND MR_F5a=2, GO TO PA_F4, ELSE GO TO EXIT SCREEN.]

PA_F4.  We are also interested in collecting the names and locating information for the providers who treated each patient while they received services in this facility in 2010.  Can you provide this information as well?

YES............................1 (GO TO CONTACT BLOCK)
NO..............................2 (GO TO PA_F4a)

PA_F4a.  Can you please provide the name and number for whom we should contact to obtain this information?

YES............................1 (GO TO CONTACT BLOCK)
NO..............................2 (GO TO EXIT SCREEN)

SECTION PA_G:  VERIFY RECEIPT OF AFS

PA_G_Intro
May I please speak to [POC]?

PA_G1.  (Hello, my name is (YOUR NAME).)  I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.

(We've confirmed that the authorization form[s] we sent in order to receive permission for the release of information [has/have] been received.)

Did you receive the [authorization form[s]/information explaining the study] we [faxed/mailed] to you?

YES, RECEIVED ALL=1 (IF PA_F1 = 1 GO TO PA_G2. IF PA_F1 = 2 OR 3 GO TO PA_G4.)
YES, BUT PROBLEM REPORTED/NEEDS A RE-SEND = 2 (GO TO PA_G5)
NO = 3 (GO TO PA_G5)

PA_G2. [N/A]  If it is convenient for you, we can just go ahead and complete the data forms together over the phone right now. I'd be happy to hold on while you get the information you need from your records.

WILL COMPLETE BY PHONE NOW ....................................... 1 (GO TO EXIT SCREEN)
WILL COMPLETE BY PHONE IN THE FUTURE .......................... 2 (GO TO PA_G3)

IF THE POC WANTS TO COMPLETE BY PHONE NOW, YOU WILL EXIT THE CONTACT GUIDE AND RETURN TO CMS.  CODE THE CASE AS "AUTHORIZATION FORMS RECEIVED - READY FOR PHONE DATA COLLECTION". THEN, PROCEED TO THE PATIENT LISTING SCREEN TO BEGIN EVENT FORM DATA COLLECTION.

PA_G3. [N/A]  I understand. What would be the best day and time to call you back to complete the data forms?

• PROBE FOR THE BEST DATE AND TIME.

• IF THE PERSON ON THE PHONE IS HESITANT TO PROVIDE AN EXACT TIME OR DATE:

  -ASK WHICH DAY OF THE WEEK IS BEST
  -ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING
  GUIDELINES FOR SCHEDULING:

  • EARLY MORNING = 9AM
  • LATE MORNING = 11AM
  • EARLY AFTERNOON = 2PM
  • LATE AFTERNOON = 4PM

  
  DATE
  TIME (HRS / MINS)
  TIME ZONE:

  ONCE THE APPOINTMENT IS SET, EXIT TO CMS AND CODE THE CASE.

PA_G4. [N/A]  Our records indicate that you will (fax/mail) the records to us. We hope you can do so within two weeks. 

YOUR NEXT STEP WILL BE TO EXIT THE CONTACT GUIDE AND CODE THE CASE AS "AFs RECEIVED, WAITING FOR RECORDS TO BE SENT."

[GO TO EXIT SCREEN]

PA_G5.  I'm sorry. Let me re-send the [authorization form[s]/information explaining the study] to you. I need to be sure I have the correct information for the packet. Should I direct it to you?

YES = 1
NO = 2

• IF ASKED CLICK HERE FOR PATIENT NAMES AND OTHER IDENTIFYING INFORMATION

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S):  In order to remain HIPAA compliant, I need to send you the authorization form[s] first.  Once you have received the form[s], then we can arrange for the collection of the data.

• CLICK NEXT TO PROCEED TO THE CONTACT BLOCK AND ENTER OR EDIT CONTACT INFORMATION FOR THE POC WHO SHOULD RECEIVE THE PACKET. THEN EXIT THE CONTACT GUIDE AND CODE THE CASE IN CMS.

  [GO TO CONTACT BLOCK]

SECTION PA_H:  BAD BILLING SERVICE INFO

PA_H1.  ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE

This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services.
For quality assurance and training purposes, this call may be monitored.

We previously spoke about the MEPS study. Thank you for providing the contact information for [BILLING SERVICE NAME]. Unfortunately we were unable to locate [BILLING SERVICE NAME] with the contact information you provided. Could you please verify the contact information we currently have for [BILLING SERVICE NAME]?

BILLING SERVICE CONTACT INFO IS CORRECT =1 (GO TO PA_H2)

BILLING SERVICE CONTACT INFO IS NOT CORRECT =2 (GO TO CONTACT BLOCK)

PA_H2. That is currently the information we have on file. Do you know of any other way we can get in touch with [BILLING SERVICE NAME]?

YES = 1 (GO TO CONTACT BLOCK)
NO = 2 (GO TO EXIT SCREEN)

IF PERSON ON THE PHONE SAYS NO, BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION PA_I:  ANY OTHER BILLING SERVICE?

PA_I1. ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE

This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored.

We previously spoke about the MEPS study. Thank you for providing the contact information for [BILLING SERVICE NAME]. we were able to locate [BILLING SERVICE NAME] with the information you provided. However, they reported that they did not maintain the billing records for [PROVIDER(S)] in 2010. Could you please check to see if another billing service maintained billing records for [PROVIDER(S)] in 2010?

OTHER BILLING SERVICE MAINTAINED RECORDS.................. 1 (GO TO CONTACT BLOCK)
NO OTHER BILLING SERVICE MAINTAINED RECORDS............ 2 (GO TO EXIT SCREEN)

IF PERSON ON THE PHONE SAYS NO, BE SURE TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION AO_A:  PROVIDER/AO CONTACT

AO_A1.  (READ IF NOT OBVIOUS: Have I reached [POC NAME]?)

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR),
  -OR- SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.

• IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER.

• IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE PROVIDER. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE PROVIDER.

• IF NO BETTER NUMBER IS AVAILABLE, SELECT "NO" BELOW.

YES.........................= 1 (GO TO AO_A2)
NO...........................= 2 (GO TO AO EXIT SCREEN)

AO_A2.  [INTRODUCTION TO IDENTIFY A RESPONDENT]

IF AO POC WAS PROVIDED BY MEDICAL RECORDS OR PATIENT ACCOUNTS:

May I please speak to [POC NAME]?

IF NO AO POC WAS PROVIDED BY MEDICAL RECORDS OR PATIENT ACCOUNTS::

"Can I please speak to someone in the administrative office who can help me with contacting/locating information for providers?"

• IF THE PERSON YOU NEED TO TALK TO IS UNAVAILABLE, ATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

CONTINUE = 1 (GO TO AO_A3)
ADMINISTRATIVE OFFICE; NOT CLEAR WHO TO SPEAK TO = 2 (GO TO EXIT SCREEN)

AO_A3. [INTRODUCTION FOR RESPONDENT]

(READ IF NECESSARY: (Hello,) my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services.  We are conducting MEPS which is a study about how people in the United States use and pay for health care. 

Earlier, your medical records department gave us information about the care that some of our study participants received at your facility and the names of the providers of that care.  Now we need locating information for those providers and whether the charges for their services would be included in the hospital's bill or billed separately by the provider. Can you provide this information?

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON,
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH -
  ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

  PERSON IS ON THE PHONE.........................= 1 (GO TO AO_A4)
  PERSON IS NOT AVAILABLE/CALL BACK..........................= 2 (GO TO APPOINTMENT SCREEN)

AO_A4. [AO1]  For quality assurance and training purposes, this call may be monitored. If it is convenient for you, I can collect this locating information over the phone right now. I'd be happy to hold on while you get the information you need from your records.

WILL COMPLETE BY PHONE NOW 1 (GO TO AO_A5)
WILL COMPLETE BY PHONE IN THE FUTURE.......................... 2 (GO TO AO_A4a)

AO_A4a. I understand. What would be the best day and time to call you back to collect this information?

• PROBE FOR THE BEST DATE AND TIME.
  
• IF THE POC IS HESITANT TO PROVIDE AN EXACT TIME OR DATE:
  -ASK WHICH DAY OF THE WEEK IS BEST
  -ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING GUIDELINES FOR SCHEDULING:
  • EARLY MORNING = 9AM
  • LATE MORNING = 11AM
  • EARLY AFTERNOON = 2PM
  • LATE AFTERNOON = 4PM

  DATE:
  TIME: (HRS/MINS)
  TIME ZONE:

  [GO TO EXIT SCREEN]

SBD SUBROUTINE
[SYSTEM WILL PULL UP THE LIST OF PROVIDERS THAT WAS COLLECTED IN MR SECTION.]

SBD_CGINTRO. I want to ask about [PHYSICIAN NAME], whose specialty is [SPECIALTY]. This doctor was reported as someone who bills separately for services.

SBD_CG7. Could you please provide the following contact information for [PHYSICIAN NAME]?

Name of Group (If applicable): 

Street: 

City: 

State: 

Zip: 

Phone: 

SBD_CG8a.  Can you tell whether this physician bills separately or has charges included in the hospital bill?

BILLS SEPARATELY = 1
CHARGES INCLUDED IN HOSPITAL BILL = 2
BILLING ARANGEMENT VARIES (SPECIFY) = 3
DON'T KNOW = 4

SBD_CG8b. Does this physician use a billing service?

YES 1 (GO TO SBD_CG9)
NO 2 (GO TO SBD_CG10)

SBD_CG9. Could you please provide the following contact information for the billing service used by this physician?

Name of Billing Service: 

Street:  

City: 

State: 

Zip: 

Phone: 

SBD_CG10. RECORD ANY NOTES AO GIVES ABOUT [PHYSICIAN NAME]

[REPEAT SBD_CGINTRO THROUGH SBD_CG10 FOR EVERY PROBIDER WHO WAS CODED A R_NODE.SBDBILL=1 IN SBD_EF5.]

SBD_CG11.  WAS INFORMATION PROVIDED FOR ALL/PROVIDERS/SBDs IN THE LIST?

INFORMATION PROVIDED FOR ALL PROVIDERS/SBDs LISTED............1 (GO TO EXIT SCREEN)
INFORMATION NOT PROVIDED FOR ALL PROVIDERS/SBDs LISTED........2 (GO TO SBD_CG12)

SBD_CG12.  Who would be able to help me with the information for the remaining providers?

ADDITIONAL AO POC PROVIDED = 1 (GO TO CONTACT BLOCK)
DK; NO ADDITIONAL AO POC PROVIDED = 2 (GO TO EXIT SCREEN)

SECTION J:  GAINING PERMISSION

INTRODUCTION:

May I please speak to [POC NAME]?

Hello, my name is (YOUR NAME).

I am calling on behalf of the U.S. Department of Health and Human Services.  We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

I recently spoke with (POC YOU ARE WORKING WITH FOR DATA COLLECTION) about the study.  I explained that at this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2010. [The/Each] patient signed an authorization form allowing us to contact you for information about the diagnoses, services and the cost of the care provided by [PROVIDER] in 2010. Much of the information we need is within the (billing records/medical records).

(POC YOU ARE WORKING WITH FOR DATA COLLECTION) has agreed to participate and provide us with the information we are looking for, but has requested that we first send you a copy of the authorization form[s] in order to receive permission to release the data to us.

I'm calling to confirm that you are in fact the best person to receive the forms[s] and information about the study by fax, and confirm your contact information so that I can address the fax to you.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS BY MAIL.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON AND RESTART THIS SECTION,
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH   ENTER THIS INTO THE CONTACT BLOCK.

• PRESS NEXT TO CONTINUE TO THE CONTACT BLOCK

[GO TO CONTACT BLOCK]

VERIFY PERMISSION PACKET RECEIPT:

May I please speak to [POC NAME]?

(Hello, my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services. We previously spoke about the MEPS study. For quality assurance and training purposes, this call may be monitored. Did you receive the authorization form[s] we sent to you?

• IF THE PERSON ON THE PHONE DID RECEIVE THE FORMS, ASK:
  
• Do you have any questions or concerns about the study information or the forms we sent?
  
• At this point may I follow-up with (POC YOU ARE WORKING WITH FOR DATA COLLECTION) about the release of data?
  
• IF YOU ARE CLEARED TO SPEAK WITH THE POC YOU ARE WORKING WITH FOR DATA COLLECTION,
  
• EXIT TO THE CMS, MAKE THE POC YOU ARE WORKING WITH FOR DATA COLLECTION THE PRIMARY POC ON THE POC SCREEN.
  
• CALL THEM USING SECTION MR_G: VERIFY RECEIPT OF AFs IF DEALING WITH MEDICAL RECORDS OR SECTION PA_G: VERIFY RECEIPT OF AFs IF DEALING WITH PATIENTS ACCOUNTS.


• IF THE PERSON ON THE PHONE DOES NOT GIVE YOU PERMISSION
  
• EXIT TO THE CMS TO CODE THE CASE AS "CASE REQUIRES SUPERVISOR REVIEW" AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS
  
• IF THE PERSON ON THE PHONE DID NOT RECEIVE THE FORMS, SAY:
  
• I'm sorry. Let me re-send the authorization form[s] to you.
  
• GO TO THE CONTACT BLOCK BY PRESSING NEXT AND VERIFY THE CONTACT INFORMATION WE HAVE ON FILE, THEN
  
• EXIT TO THE CMS AND TRIGGER A RE-SEND OF THE PERMISSION PACKET TO THIS PERSON.

[GO TO CONTACT BLOCK]

CONTACT BLOCK

IF YOU ARE BEING REFERRED A NEW POC BY SOMEONE ELSE, COLLECT ONLY NAME AND PHONE NUMBER.

IF YOU WOULD LIKE TO EDIT OR VERIFY INFORMATION FOR A POC YOU HAVE ALREADY COLLECTED INFORMATION FOR, CLICK "EDIT" NEXT TO THEIR NAME IN THE TABLE ABOVE.

IF UPDATING OR VERIFYING A POC FOR SENDING A MAIL/FAX PACKET, TRY TO COLLECT/ VERIFY ALL FIELDS.

IF GIVEN INFORMATION FOR SOMEONE OTHER THAN THE PERSON ON THE PHONE, ALWAYS ASK TO BE TRANSFERRED TO THAT PERSON.

CONTACT FIELDS

PROVIDER NAME:

MEDICAL RECORDS/BILLING SERVICE NAME:

POC FIRST NAME:

POC LAST NAME:

PHONE:

EXT:

FAX:

VERIFY FAX:

TITLE:

DEPARTMENT:

ADDRESS:

CITY:

STATE:

ZIP:

FOLLOW-UP QUESTIONS

CB1.  WORK WITH THIS POC ON THE NEXT STEP/CALL?

1. YES
2. NO

CB2a. WHICH SECTIONS OF THE CONTACT GUIDE APPLY TO THIS POC?

1. MEDICAL RECORDS
2. PATIENT ACCOUNTS
3. ADMINISTRATIVE OFFICE
4. MEDICAL RECORDS AND PATIENT ACCOUNTS
5. MEDICAL RECORDS AND ADMINISTRATIVE OFFICE
6. PATIENT ACCOUNTS AND ADMINISTRATIVE OFFICE
7. MEDICAL RECORDS, PATIENT ACCOUNTS AND ADMINISTRATIVE OFFICE POC

CB2. WHAT TYPE OF POC DID YOU ENTER INFORMATION FOR?

1. PROVIDER LEVEL GATEKEEPER
2. HANDLES RELEASE OF IN-HOUSE RECORDS
3. DEALS WITH MEDICAL RECORDS SERVICE
4. DEALS WITH EXTERNAL BILLING SERVICE
5. MEDICAL RECORDS SERVICE GATEKEEPER
6. EXTERNAL BILLING SERVICE GATEKEEPER
7. HANDLES RELEASE OF RECORDS FOR MEDICAL RECORDS SERVICE
8. HANDLES RELEASE OF RECORDS FOR EXTERNAL BILLING SERVICE
9. ADMINISTRATIVE OFFICE POC
10. HANDLES RELEASE OF IN-HOUSE RECORDS & IS ADMINISTRATIVE OFFICE POC
11. COURTESY PACKET RECIPIENT
12. PERMISSION PACKET RECIPIENT
13. POC FOR REMAINING PROVIDERS (SBDs)

CB3. WHAT TYPE OF PACKAGE ARE YOU SENDING?

IF THE PERSON ON THE PHONE DID NOT EXPRESS A CONCERN ABOUT RECEIVING A FAX, SAY:
"To confirm, I will be sending the authorization forms by fax."

IF THE PERSON ON THE PHONE DID EXPRESS A CONCERN ABOUT RECEIVING A FAX, SAY:
"To confirm, I will be sending the authorization forms by mail."

1. FAX
2. MAIL

CB4.  ADD ANOTHER POC?

1. YES
2. NO

CALLBACK/APPOINTMENT SCREEN

Can you please provide me with a better time to call back in order to reach (him/her)?

• PROBE FOR THE BEST DATE AND TIME.
  
• IF THE PERSON ON THE PHONE IS HESITANT TO PROVIDE AN EXACT TIME OR DATE:

  -ASK WHICH DAY OF THE WEEK IS BEST
  -ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING GUIDELINES FOR SCHEDULING:

  • EARLY MORNING = 9AM
  • LATE MORNING = 11AM
  • EARLY AFTERNOON = 2PM
  • LATE AFTERNOON = 4PM

  
  

  DATE:
  TIME: (HRS / MINS)
  TIME ZONE:

  [GO TO EXIT SCREEN]

EXIT SCREEN

PRESS "FINISH" TO EXIT THE CONTACT GUIDE AND ENTER THE CASE MANAGEMENT SYSTEM.
DO NOT HANG UP UNTIL YOU REACH THE CALL DISPOSITION SCREEN.

• IF A PERMISSION PACKET MUST BE SENT, YOU MUST DO THE FOLLOWING:
1. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR RECORDS FIRST.
2. 2.MAKE A FOLLOW-UP CALL TO THE POC WHO WILL GRANT PERMISSION, USING SECTION J: GAINING PERMISSION.


• IF A COURTESY PACKET MUST BE SENT, YOU MUST DO THE FOLLOWING:
1. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR THE COURTESY PACKET FIRST.
2. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR RECORDS.

[EXIT TO CMS BY PRESSING FINISH]

PROVIDER VERIFICATION SCREEN

Before we send you the authorization form(s), I'll need to determine that all of the providers I have listed were in fact associated with this practice during 2010. I'm going to read you a list of providers, and for each one, please tell me if each one was associated with this practice in 2010.

IF A PROVIDER IS NOT ASSOCIATED WITH THIS PRACTICE IN 2010, CHECK THE BOX NEXT TO THEIR NAME. IF NO PROVIDERS ARE REMOVED FROM THE LIST, YOU MUST STILL CLICK SAVE BELOW.